UGANDA'S SUCCESS IN REDUCING HIV/AIDS PREVALENCE RATES IN THE 1980s AND 1990s more

UGANDA’S SUCCESS IN REDUCING HIV/AIDS PREVALENCE RATES IN THE 1980s AND 1990s An Integral Retrospective Analysis Katherine Coder ABSTRACT To combat the decimating HIV/AIDS virus in the 1980s and 1990s, Uganda pioneered the first comprehensive behavior change program of its kind that revolutionized the way the world saw the battle against HIV/AIDS. Over roughly 10 years, Uganda’s HIV prevalence rate among pregnant women decreased from approximately 21% to 6%. This paper studies Uganda’s highly successful and replicated HIV/AIDS behavior program using Integral Theory. Integral analysis highlights Uganda’s key factors to behavior change programming success that include the interaction of wellcoordinated systemic changes, culturally appropriate message content and delivery, and continuous commitment to research and evidence-based interventions. Integral analysis suggests that Uganda’s HIV/AIDS prevention campaign succeeded because it focused implementing systems-based (LR) interventions that incorporated cultural (LL) and intrapersonal (UL) sensitivities to promote behavior change (UR). Key words: AIDS; HIV; integral theory; international development; public health; Uganda A lthough researchers Allan Ronald and Merle Sande (2005) state that “light is appearing at the end of the proverbial tunnel” (p. 1045), the fact remains that approximately 24.5 million adults and children were living with HIV in Sub-Saharan Africa as of 2005. The 2006 Report on the Global AIDS Epidemic reports that Sub-Saharan Africa is home to just over one-tenth of the world’s population but makes up 64% of people living with HIV (“AIDS,” 2005, p. 150). Former United Nations General Secretary Kofi Annan stated that the HIV/AIDS pandemic “continues to outrun our efforts to contain it.” In 1986, one country in Africa pioneered a comprehensive behavior change program, the first of its kind. This all-inclusive program revolutionized the way the world saw the battle against HIV/AIDS. Over roughly 10 years, Uganda’s HIV prevalence rate in pregnant women decreased from approximately 21% to 6%, where it remains as of 2005 figures from UNAIDS (Gerard Health Foundation, 2003; Green, 2003b; UNAIDS, 2006; U.S. Senate, 2003).1 Prevalence is defined by UNAIDS as “the proportion of people living with HIV,” (UNAIDS, 2006, p. 8) or as the incidence rate per year multiplied by the duration of the disease in years (Mosley, 2005). Uganda achieved this feat largely by creating the distinctive approach to HIV/AIDS prevention known as “ABC,” which asked Ugandans to remain abstinent, be faithful, or use a condom (U.S. Senate, 2003). Many have theorized why Uganda was so successful (Epstein, 2007; Green, 2003b; Green et al., 2006; Ronald & Sande, 2005; Slutkin et al., 2006). Many also question the evidence that prevalence Correspondence: Katherine Coder, 494 Lassen Street, Apt. C, Los Altos, CA 94022. E-mail: freda.and.danto@mac.com. Author Affiliation: Clinical Psychology Department, Institute of Transpersonal Psychology, Palo Alto, CA, U.S.A. Journal of Integral Theory and Practice, 3(4), 2008, pp. 39–60 K. CODER rates decreased as a result of primary behavior change due to the implementation of a national behavior change campaign (Green, 2003b; Murphy et al., 2006; Roehr, 2005). Rather than continue to support or deny Uganda’s success in primary behavior change, this article assumes that Ugandan behavior change, partner reduction in particular, was highly influential in lowering HIV/AIDS prevalence rates in Uganda from 1986 to 2000.2 The purpose of this article is to analyze Uganda’s success retroactively using Integral Theory in order to construct a more complete understanding of the problem and its resolution. The Integral Framework The integral framework was introduced by and is most-widely promoted by Wilber, who defined the term integral as “unity-in-diversity, shared commonalities along with our wonderful differences” (Brown, 2006, p. 374). Wilber (2006) states that integral is comprehensive rather than reductionistic. The integral framework is “a comprehensive map of human potentials” (p. 1) that is informed by a multiplicity of research domains while concurrently focusing intently on the issue at hand (Brown, 2006). The integral framework is an outcropping of Integral Theory, which is the result of more than 30 years of inter- and transdisciplinary scholarship in which Wilber and others have integrated and blended knowledge and information from a wide range of domains that include, but are not limited to, spirituality, psychology, philosophy, anthropology, biology, sociology, sustainable development (Brown, 2006, 2007), and international development (Hochachka, 2006, 2007). The integral framework is comprised of five major components: quadrants, levels, lines, states, and types (Wilber, 2006). The quadrants provide four unique perspectives, which include the interior-individual (UL) and interior-collective (LL), which are interior viewpoints, and the exterior-individual (UR) and the exterior-collective (LR), which are exterior viewpoints. Stages, also known as levels of development, are fixed milestones in consciousness that are organized hierarchically, based on increasing measures of complexity and inclusivity. Lines of development result from the understanding that we all have different strengths and weaknesses and that our development along various lines of intelligence is not the same. Lines of development include aspects of intelligence such as cognitive, interpersonal, emotional, kinesthetic, moral, and aesthetic. States refer to states of consciousness, or temporary aspects of our subjective reality, including waking, dreaming, and deep sleep as well as peak, meditative, and altered states. Everyone experiences different states of consciousness, and those states “often provide profound motivation, meaning, and drives, in both yourself and others” (Wilber, 2006, p. 4). Finally, types can be present in any stage or state, and the major types that Wilber discusses are the masculine and feminine aspects. All five parts combined constitute the integral map, often referred to as AQAL (Brown, 2006; Wilber, 2006). This article will examine how the quadrants apply to Uganda’s HIV/AIDS crisis and innovative behavior change initiative. Rationale for Retrospective Research The purpose of this research is to describe a retrospective case study using the integral lens to support a growing community of practitioners in the field of integral international development. This case study presents an example of a public health intervention that is likely classified as integrative (Hochachka, 2008). While the HIV/AIDS interventions were not created based on Integral Theory, the overall HIV/AIDS reduction strategy was mindful of interior, exterior, individual, and collective dimensions in its efforts to produce successful interventions to reduce HIV/AIDS prevalence. 40 Journal of Integral Theory and Practice—Vol. 3, No. 4 HIV/AIDS RATES AND UGANDA My hope is that the presentation of this material may help development practitioners who are unfamiliar with Integral Theory understand the merits of an integral approach. And ultimately I would like this research to persuade more development practitioners to engage the integral model, thereby extending its application to many more projects and programs around the world. Analysis Limitations My understanding of Uganda’s successes with HIV/AIDS prevention is limited because I was not able to travel to Uganda and study the phenomenon from the inside out. I am also not a Ugandan that experienced this coordinated set of interventions personally and cannot report subjectively on the experiences of Ugandans. This undertaking is also limited by my own understanding of Integral Theory and its practical applications in development work and in research. (I would consider myself a budding integralist.) My understanding of the literature has been greatly enhanced by a course in Integral Theory taught by Mark Forman, through study of Gail Hochachka’s work and research, and finally, through an ongoing engagement with the Integral Without Borders community. Completing this retrospective analysis of Uganda’s HIV/AIDS efforts necessitated that I get clearer on Integral Theory as well as Integral Methodological Pluralism. My research study was enhanced greatly by personal communications with Dr. Edward Green, a prominent researcher of HIV/AIDS who has spent more than 20 years in Uganda. He was able to clarify nuanced aspects of this subject and review parts of my analysis, which aided me significantly in producing an accurate and valid case study. Integral Research Methodologies As this research was self-funded and undertaken without the assistance of a team of co-researchers, the methodologies that I employed represent only a partial sample of the lines of inquiry available in Integral Methodological Pluralism. The analysis is based on methodologies from zone 1, zone 2, and zones 6 and 8, most of which were informally applied. Zone 1 In zone 1, my experiential inquiry included almost 18 months of consideration of this topic, 12 of which were more or less continuous. This continuous process of research and reflection led to a progressively deeper and more comprehensive understanding of the topic. Being an extroverted thinker, I often used dialogue with others to clarify and explore my ideas. Zone 2 In zone 2, I engaged in an informal, or “folk,” developmental inquiry (Hochachka, 2008), as I have not yet trained in a more advanced methodology like Susanne Cook-Greuter’s Sentence Completion Test. My assessment of Ugandan development was based on my studies of Cook-Greuter’s Ego Development Theory, Wilber’s exploration of developmental models, Maslow’s theory of motivations, and both traditional and cross-cultural models of moral development. Engagement with most of these models has been ongoing in my process to complete my doctoral degree in clinical psychology. My assessment of Ugandan development relied heavily on my previous studies of development models as well as on dialogue with and feedback from more advanced integral practitioners who have Journal of Integral Theory and Practice—Vol. 3, No. 4 41 K. CODER deeper understandings of development as applied in this context. Beyond the Integral community, research from scholars in cross-cultural development such as Barbara Rogoff (2003) and Carolyn Pope Edwards (1975) helped me understand how development can been understood outside of the conventional paradigm. I triangulated my own assessments of Ugandan development using literature available on this topic, my own experience in developing countries, and my intuition. Notably, it was watching the video entitled, “What Happened in Uganda?” by the Gerard Health Foundation (2003) that inspired me to begin this research. It was then that I noticed that Ugandans who were represented seemed to have a developmental altitude that was quite different from the one Western public health planners assumed they had. This fact “caught me” and propelled me forward in this work. Finally, I relied on my own experience in West Africa and Haiti to gauge the developmental altitudes as well as on my own intuitive knowing. Zones 6 and 8 I engaged zones 6 and 8 by performing an informal meta-analysis of the scholarly and informal research available on this topic. I researched the systems that enabled the Ugandan success at local, national, and international levels. The literature on this topic was replete with large- and small-scale quantitative studies that examined primary behavior change and the effectiveness of specific HIV/ AIDS interventions. Analysis of these research studies is explored in discussions of the exteriorindividual and exterior-collective quadrants. The Integral Scope of the HIV/AIDS Crisis in Uganda The first AIDS case in Uganda was found in 1982 in a fishing village in the Rakai district on the shores of Lake Victoria (Bessinger et al., 2003; Demographic Health Surveys [DHS], 2001, p. 167; Uganda AIDS Commission Secretariat, 2002). By 1986, 910 cases were reported and, in 1988, that number had risen to 7,249 (Uganda Ministry of Health, n.d.). In a study completed in 1986-1987, 86% of sex workers and 33% of lorry drivers were HIV-positive (Slutkin et al., 2006). By 1988, Uganda “had one of the highest rates of HIV infection in Africa” (Bessinger et al., 2003, p. 3). In May 2003, Dr. Edward C. Green, Senior Research Scientist at Harvard’s Center for Population and Development Studies reported to the U.S. Senate Foreign Relations Committee that Uganda’s infection rates rose to 21% in 1991. Studies of prevalence rates in pregnant women in the Ugandan capital of Kampala were 30% in this same period (USAID, 2003). Additionally, studies by the Global Program on AIDS in 1989 found that the number of men and women reporting one or more casual partners was 35% and 16%, respectively (Bessinger et al., 2003). To analyze the scope of the Ugandan HIV/AIDS crisis integrally, this article will examine key aspects of the AQAL model, including quadrants, stages, and lines of development. Due to the limitations of this article, all aspects of the collective and individual Ugandan environment and experience will not be explored. It is also important to note that while this article presents features of the Ugandan situation housed in single quadrants for ease of readability, these factors are multi-dimensional, often mutually arising in multiple quadrants, and interactive, creating complex interactions that affect realities associated with all quadrants. Hochachka (2006) writes that the quadrant model shows that the spread of HIV/AIDS relies not only on the biology of the disease itself, but “also relates to people’s 42 Journal of Integral Theory and Practice—Vol. 3, No. 4 HIV/AIDS RATES AND UGANDA traditions and beliefs, and those behaviours, social norms, and institutions with [sic] correlate with those traditions and beliefs” (p. 16). Collective Exterior (LR) Fundamentals in Uganda The LR dimension contains information about the society, such as its sociopolitical and economic systems as well as its physical environment (Brown, 2006, 2007; UNDP et al., 2006, pp. 105-106). Joseph Friedman (2005), a UNDP consultant, explained that the LR dimension includes society, written laws, allocation of resources, and ritual. Relevant to this quadrant is Uganda’s status as an agrarian-industrial economy with a burgeoning democratic political system. Thompson (2003) writes that Uganda had a relatively benign colonial experience with the British as compared to other African countries. The British found Uganda to have fertile land, and Britain encouraged Uganda to increase production and trade with the Indians. White settlement was discouraged, most land remained in Ugandans’ possession, and some tribal groups continued their traditional way of governing. Uganda’s fertility and more equitable land ownership may have contributed to Uganda’s greater success with structural adjustment programs and its resultant prosperity (Epstein, 2004, 2007). As such, a “prosperous Ugandan middle class emerged, whose children were eager for education and advancement in such modern professions as medicine, law, and administration” (Epstein, 2007, p. 63). Although Idi Amin (Uganda’s President from 1971-1979) killed and forced into exile many of the talented doctors and scientists that Uganda produced in the 1970s, a small group remained and was available to help at the time of the HIV/AIDS crisis in the mid-1980s. Others, including Dr. Vinand Nantulya and Dr. Edward Green, were in neighboring Kenya and were available to current President Yoweri Museveni at the outset to work with HIV/AIDS (Green, personal communication, March 13, 2008). Group, or society-wide, behaviors also are features of the LR dimension (Brown, 2006). The Ugandan societal patterns of sexual behavior are an important aspect of this quadrant in this case study. Some of the literature reviewed showed that Ugandans’ sexual partnering is concurrent (Epstein, 2007; Robinson et al., 1999). From his research and experience in Uganda, Green believes that concurrent sexual partnering was occurring in Uganda but that it was not as common as it was in Southern Africa where men were often separated from their wives for long periods while they worked in South Africa (personal communication, March 13, 2008).3 Epstein (2007) describes concurrent sexual partnering as engaging in a small number of long-term sexual relationships. As cited in Epstein (2007), Morris found that in Uganda about 40% of men and 30% of women reported that “at least two of their most recent relationships overlapped for several months or years” (p. 57). HIV spreads very quickly through a society in which long-term concurrent partnering is established. Condoms are seldom used in spite of heroic efforts at promotion, since condoms are universally seen as a sign that a partner is untrustworthy (DHS, 2001, p. 187; Epstein, 2007, p. 59; Green, personal communication, March 13, 2008; Morris & Kretzschmar, 1997). Furthermore, because HIV infectiousness rises steeply in the first three weeks after infection, long-term concurrency networks enable an even more rapid spread of the virus, as sexual partnering occurs often in intervals of days and weeks when the viral load of a newly infected person is extremely high (Epstein, 2007; Halperin, 2007; Morris & Kretzschmar, 1997; USAID, 2006). Lastly, society-wide deaths and infection rates in Uganda resulting from HIV/AIDS are systemic and fall into the LR quadrant. Journal of Integral Theory and Practice—Vol. 3, No. 4 43 K. CODER Collective Interior (LL) Fundamentals in Uganda The LL dimension refers to intersubjective realities including shared values, culture, worldview, norms, and customs (Brown, 2006, 2007). Utilizing Jean Gebser’s stages of worldview, some of the Ugandan populace would reside in the magic stage where man experiences unity and connectedness (Mickunas, 1997). Other Ugandans reside in the mythic stage, where beliefs are absolutistic and ethnocentric, and the mental-rational stage, where individual perspectives exist alongside the incorporation of science into daily life (Mickunas, 1997; Wilber, 2006). Ugandan shared values and culture are more deeply understood by examining the cultural philosophy and ethic of ubuntu, which is a foundation of the Bantu peoples of Sub-Saharan Africa (Ramose, as cited in Karsten & Illa, 2005). Ubuntu is considered to be the “ultimate African virtue” (Hanks, 2008, p. 126). Ubuntu represents a cultural belief found in many cultures around the world, although Mluleki Mnyaka and Mokgethi Motlhabi (2005) suggest that ubuntu differs from other world philosophies and is uniquely African. Van Dyk and Nefale (2005) explain that among the African people, ubuntu is thought of as the most important quality of a human being. Ubuntu represents humanness, or “an inner state of complete humanization,” (p. 54) and it is founded on a cosmology that stresses interdependence, communality, (Bangura, 2005; Van Dyk & Nefale, 2005), and harmony (Van Vlaenderen, 1999). Ubuntu is an African philosophy that is embedded in people’s daily lives (Karsten & Illa, 2005). Furthermore, ubuntu embodies the core values of African ontologies and is also a value system that regulates African societies. This value system includes a) respect for all human beings, b) respect for human dignity and life in particular, and c) “collective sharedness, obedience, humility, solidarity, caring, hospitality, interdependence, and communalism” (Van Dyk & Nefale, 2005, p. 55). Ubuntu is a concrete ethic that places the individual squarely in association with the community. “Ubuntu is not a state of being but of becoming” (Ramose, as cited in Murove, 2004, p. 204). Further, ubuntu is made manifest through human action: how one relates to their surroundings and to others is a major indicator of their humanness (Karsten & Illa, 2005; Murove, 2004). Individuals are not seen as self-sufficient and independent; this worldview explicates interdependence as the true reality and necessitates that a person be responsive to others’ needs. Obligations to the community are of critical importance (Karsten & Illa, 2005; Murove, 2004). Bangura contrasts the ubuntu idea of individuality, which means “being-with-others” (Bangura, 2005, p. 33), with the Western idea of individuality. In the Western worldview, society is a backdrop to the existing and self-sufficient individual being. Ubuntu is in direct contradiction to the Cartesian individual that can be conceived of alone, without others. Whereas the West often equates individualism with “rugged competition” (Bangura, 2005, p. 33), Africans prefer cooperation and teamwork.4 In summation, Munyaradzi Murove (2004) writes, A person who has ubuntu is someone who puts the concerns of others before his or her own. In this way of living, one does not do something good because of a god’s commandments; rather, one does something good because it is primarily what it means to be human. (p. 204) It is important to note that while ubuntu is held as a cultural value, it is “an ideal which is sometimes very difficult to fulfill” (Mnyaka & Motlhabi, 2005, p. 231). In fact, its presence as a cultural value may not be at all apparent to outsiders when one takes stock of the xenophobia and the explicit and implicit acts of tribal warfare manifest in various parts of Sub-Saharan Africa. Mnyaka and Motlhabi 44 Journal of Integral Theory and Practice—Vol. 3, No. 4 HIV/AIDS RATES AND UGANDA explain that this phenomenon is the result of events that have “threatened, challenged, misused, and almost destroyed” (p. 232). African culture, and that while ubuntu may have been negatively affected, its essence is still present in the core being of Africans. This spirit of communalism is evident in another facet of Ugandan culture: strong social cohesiveness. Research has suggested that high social or family cohesion was present in Uganda at the time the AIDS crisis reached its zenith (Green, 2003b; Stoneburner & Low-Beer, 2004; USAID, 2002). The communication style of the Ugandan populace is related to social cohesion. Ugandans generally communicate through interpersonal, or face-to-face, channels rather than through mass media (Wilson, 2004). The cultural stigma surrounding HIV/AIDS is another LL consideration (Ronald & Sande, 2005). High stigma levels evolved as “most Ugandans thought of the disease as witchcraft and later (thought of HIV/AIDS as) a disease of the immoral” (Uganda AIDS Commission Secretariat, 2002). The Ugandan traditions of polygamy and monogamy (Green, 2003b) also involve LL considerations. Individual Interior (UL) Fundamentals in Uganda Barrett Brown (2007) explains that that the UL quadrant focuses on intelligence and experience. The UL quadrant focuses on the subjective experience of the individual, and this may refer to such aspects as states of mind, psychological development, emotions, and will (Brown, 2006, 2007; Wilber, 2006). This quadrant houses an individual’s different subjective stages, states, and lines of development. One prominent component of this quadrant would include the stages, or levels, of ego development of Ugandans. Ego development falls on the developmental line for self-identity. In light of Cook-Greuter’s stages of ego development (Cook-Grueter, n.d.), the typical Ugandan most likely falls between the preconventional and conventional level of ego development. A proportion of Ugandans likely fall into the preconventional level of ego development, given that many Ugandan are likely not to have had educational and life advantages that would encourage movement into higher stages of development. Following Cook-Greuter’s model of ego development, these Ugandans would fall into the Self-Protective/Opportunist stage where life is considered to be a zero-sum game, and one assumes the worst about others’ intentions. Opportunists only see the world from the viewpoint of “their own needs and wants;” (p. 9) they work to control others and protect themselves; and black and white thinking is the norm. Opportunists have an expedient morality: an action is wrong only if one is “caught and punished” (p. 10). Their coping styles are immature, and they use blaming and distortion to decrease anxiety and increase self-esteem. For Ugandans in conventional ego development, some would appear as Conformists. In the Conformist stage, an individual’s identity is defined by their relationship to a group. The individual finds protection and power in the group. In this stage, one accepts the in-group totally and rejects the outgroup completely; it is the stage of the “us” versus “them” mentality. Ambiguity and ambivalence go unnoticed in this stage, as they threaten the core identity of the Conformist. In this phase, material assets and status symbols are satisfying and meaningful, demonstrating one’s success in the world. Life for the Conformist is defined by rules of appropriate behavior, and shame is common if the “shoulds” of life go unfulfilled (Cook-Greuter, n.d.). Journal of Integral Theory and Practice—Vol. 3, No. 4 45 K. CODER Given the Ugandan’s motivation toward education and economic capacity to pursue professionalization (Epstein, 2007), some individual Ugandans with more advanced learning opportunities likely led them into further levels of ego development. Following Cook-Greuter’s (n.d.) model, these individuals may have moved into the Self-Conscious/Expert stage of ego development or the Conscientious stage of ego development. In the Self-Conscious/Expert stage, individuals take a third-person perspective and are capable of “some introspection and self-understanding” (p. 15). Moving away from the group mentality, Self-Conscious persons see their individual differences and assert their own needs and wants. They want to be better than others and feel that they have “figured it all out” (p. 16). Their world is clear, and they feel entitled to impose their beliefs on others. In the Conscientious stage, individuals are “rationally competent and independent” (Cook-Greuter, n.d., p. 17). They associate with others that have similar values and aspirations, have “internalized societal standards,” and they believe in the scientific method to find truth. In this stage, truth is knowable. They are curious and interested in what drives them—especially root causes—and are capable of greater levels of introspection. They begin to notice inconsistencies in themselves and also in their belief systems. They are serious, idealistic, and enthusiastic about their work in the world, and they have intense and meaningful interpersonal relationships. They see themselves as a part of community and society and also as “separate and responsible for their own choices” (p. 20). The developmental line for morality is viewed through the lens of Lawrence Kohlberg (1984), a pioneer in the field of moral development, and through the work of cross-cultural development scholars such as Carolyn Pope Edwards (1975) and Barbara Rogoff (2003). The typical Ugandan in the mid to late 1980s appears to fall into either the preconventional or conventional stage of Kohlberg’s stages of moral development, depending on their level of formal education, employment in the white collar professional sector, position in society, and the level of urbanization present in their place of residence.5 Wilber (2006) describes conventional morality as the ethnocentric stage where the individuals’ moral outlook is centered in their own culture’s moral code. Given the debate on the viability of Kohlberg’s scale in cross-cultural settings (Edwards, 1975; Harkness et al., 1981; Kohlberg et al., 1983; Rogoff, 2003), the Ugandan line of moral development must also be understood from a cross-cultural perspective. Rogoff (2003) writes that the communities that fall outside those in which Kohlberg’s moral reasoning scale was developed perform “lower” on the scale. Harkness and colleagues (1981) further state that although Kohlberg asserted that his scale applied to all individuals regardless of social context, “differences in moral thought and behavior may reflect adaptations to the social functions they regulate rather than individual developmental differences” (p. 602). The developmental line for motivation is analyzed using Abraham Maslow’s (1943) theory of human motivation. Regarding the motivation line in terms of Maslow’s hierarchy of needs, the average Ugandan most likely falls in several different categories depending on their exact socioeconomic status, but is probably primarily motivated toward survival, safety and security, love and belonging, or esteem depending on their individual circumstance. Given that Maslow theories are linked with the development of apartheid in South Africa (Lambley, 1973), it seems that including Maslow in assessing development in this example is likely to be met with uneasiness in some circles. I suggest that this uneasiness calls for greater communication between Western and African psychologists, philosophers, and others with knowledge about development to determine how best to envision development 46 Journal of Integral Theory and Practice—Vol. 3, No. 4 HIV/AIDS RATES AND UGANDA from an African perspective, as context is inextricably linked with theory (Lambley, 1973). Individual Exterior (UR) Fundamentals in Uganda Brown (2007) explains that that the UR quadrant refers to body and behavior. This quadrant is concerned with “What I do,” (p. 376) including visible biological features and behaviors. The literature reviewed showed that Ugandans’ individual sexual behaviors varied widely and included engaging in unprotected sex, sex with multiple partners in long-term concurrent or casual short-term relationships, monogamous sex, abstinence, and early sexual debut (DHS, 2001; Epstein, 2007; Green, 2003b; Robinson et al., 1999; Stoneburner & Low-Beer, 2004; Uganda AIDS Commission Secretariat, 2002). Allison Herling (2004), a researcher who studied abstinence in Ugandan youth, reports that education and the hope of a ‘bright future’ are the biggest motivating factors for youth to delay sexual debut. The youth’s decision to engage in sexual behavior is also affected by social, family, and religious influences. Lastly, studying individual behavior through statistical analysis also is associated with the UR. Integral Analysis of Uganda’s Behavior Change Program Before deconstructing the Ugandan HIV/AIDS prevention program, it is important to note the positive effects of integral program development in sustainable development and, particularly, in international development. Sustainable development ventures are much more likely to succeed if they “respond to all the major influences that arise from each quadrant,” (Brown, 2006, p. 393) including individual consciousness and behavior as well as collective culture and systems (Brown, 2007; Hochachka, 2005, 2006). Furthermore, each quadrant affects and is affected by all of the other quadrants; the quadrants are mutually determining. For example, re-visiting the Ugandan landscape before 1986, lack of government programming on HIV/AIDS (LR) and cultural stigma against HIV/AIDS (LL) were two factors that contributed to the dearth of personal understanding (UL) of the disease and virtual absence of personal will (UL) to refrain from behaviors (UR) that continued the transmission of HIV/AIDS. With this more sophisticated appreciation of the AQAL map in mind, the Ugandan HIV/AIDS behavior change strategy will be analyzed to establish its efficacy from each of the four perspectives. Given the limited scope of this article, only a survey of the most significant parts of Uganda’s program will be explored. Critical Systems–based (LR) Interventions and Change in Uganda Sustainable development programs aim to and are most qualified to effect change in the LR, or systems-oriented, quadrant (Brown, 2006, 2007). Uganda was no exception to this trend. The program began in 1986 when President Museveni decided it was necessary to fight the spread of HIV/AIDS (Gerard Health Foundation, 2003). Ronald and Sande (2005) describe Museveni’s leadership as “inspired” (p. 1046), and the major reason Uganda was so successful was that its government took an active role in planning the overall strategy to combat the disease (Green, 2003b; Green & Witte, 2006; Okware et al., 2001; Shelton et al., 2003; Slutkin et al., 2006; Uganda AIDS Commission Secretariat, 2002; Uganda Ministry of Health, 1999). President Museveni not only changed government structures to meet the challenges of HIV/AIDS, he also involved a significant number of public and private organizations from the international, Journal of Integral Theory and Practice—Vol. 3, No. 4 47 K. CODER national, and village levels (Green, 2003b). The combined involvement of the president, faith-based organizations, political bodies, community-based organizations, the military, the health care system (including the modern/biomedical and the traditional/indigenous systems [Green, 2000]), the educational system, and local and countrywide communications systems encouraged a mass behavior change to avoid risky sex (Shelton et al., 2003; Uganda AIDS Commission Secretariat, 2002). Notably, it is widely reported that faith-based organizations and religious leaders participated in preventing the transmission of HIV/AIDS and in educating their constituents in the realities of the disease (Green, 2003a, 2003b; Green et al., 2006; Ronald & Sande, 2005; Slutkin et al., 2003; USAID, 2002; U.S. Senate, 2003). Imams and church leaders provided the major source of information for around 12% of the population (Slutkin et al., 2006). Anglican clergy delivered HIV prevention messages in sermons, weddings, and funerals (Green et al., 2006; Kaleeba et al., 2000). In addition, the Ugandan government trained thousands of traditional healers who became active in the prevention effort. Traditional healers are influential in religious and spiritual matters as well as in health domains. Green (2003b) describes them as “ideal AIDS educators and behavior change agents” (p. 201). The Ugandan government encouraged traditional healers to combine their training in HIV/ AIDS prevention and treatment with their traditional approaches to create joint interventions (Green, 2000, 2003b). In this climate of increasing social and political openness about HIV/AIDS (Okware et al., 2001; Uganda Ministry of Health, 1999; USAID, 2002), another social movement began that helped create more openness around the disease. In Uganda, people living with HIV/AIDS (PLWHAs), “visited schools, churches, and local communities, teaching about the disease and speaking candidly about their personal experiences” (Green, 2003b). Research showed that the Ugandan PLWHAs who worked as trainers to educate youth about HIV/AIDS to influence them to adopt safe sexual practices were successful (Sekirevu & Lukenge, 1998). The AIDS Support Organization (TASO) formed in 1987, which “advocated against discrimination and stigma while pioneering a community-based approach for care of PLWHAs” (USAID, 2002, p. 6). This movement of PLWHAs helped to decrease stigma (LL), educate individuals and change their knowledge base (UL), and influence individuals to practice safer sexual behaviors (UR). In order to change individual and group behavior, Museveni’s team of leaders and advisers created the Information, Education and Communication (IEC) campaign, a vital part of Uganda’s AIDS Control Program, which was supported by crucial organizations including World Health Organization (WHO) and UNICEF. Slutkin and colleagues (2006) describe Uganda’s IEC program as “the most widespread, extensive and well thought-out [IEC] program for AIDS prevention (and care) of any country in Africa” (p. 354). In 1986, the IEC launched an aggressive behavior change communications program using a variety of media, including print, radio, and billboards. The IEC program trained thousands of community-based HIV/AIDS health educators and counselors (Green et al., 2006; Shelton et al., 2003). The message of the IEC’s prevention program was “ABC” (be abstinent, be faithful, and use a condom correctly and consistently). This comprehensive approach contains the crucial elements necessary for combating the spread of the disease. The ABC model recognizes that everyone is different, and that one message will not be effective for all. This model supports a range of behavioral options for prevention (U.S. Senate, 2003). 48 Journal of Integral Theory and Practice—Vol. 3, No. 4 HIV/AIDS RATES AND UGANDA The ABC program was intended explicitly to change or maintain sexual behavior. The abstinence messaging urged youth to delay their sexual debut, preferably until they were married; in fact, the word abstinence was rarely used. The Ugandan model placed particular importance on being faithful, also called zero-grazing. Zero-grazing was the dominant message in Uganda. It referred to how traditionally cattle were limited to feeding only in their own pasture. Monogamist Ugandans were encouraged to be faithful to their wife, husband, or to the person they were sexually involved with at the time (Slutkin et al., 2006). Polygamist Ugandan men were asked to be faithful to their wives, and their wives were asked to be faithful to them (Green, 2003b). In concurrence with President Museveni, the Ministry of Health, which led Uganda’s AIDS Control Program for several years, was not eager to endorse condom promotion as a way to reduce HIV prevalence rates, as there were problems with condom availability, acceptability, disposal (Slutkin et al., 2006), and in efficacy in preventing the spread of the disease (Green, 2003b). It is important to note that while large percentages of Ugandans did not use condoms, the high-risk populations were encouraged to and did. Both the majority of men (59%) and a large proportion of women (38%) who reported having multiple partners stated they had used a condom with their last non-regular partner. However, it should be noted that the denominators here were small; most Ugandans did not have nonregular partners. In addition, by the late 1990s, reported condom usage by commercial sex workers had reached nearly 100% in Kampala (Green et al., 2006).6 Educating youth through schools about HIV/AIDS prevention was a priority for the Museveni government (Green, 2003b; Herling, 2004). The government brought HIV/AIDS sensitization and preventive education to primary schools beginning in 1987 (Green, 2003b; USAID, 2002). This program was called the School Education Health Program (SHEP) and was part of the Ministry of Education. It aimed to reach youth with information to prevent AIDS before their sexual debut, primarily through promoting abstinence, although SHEP also taught correct condom usage. SHEP trained students as peer educators as well, and these youth educators were expected to teach their parents and peers about HIV/AIDS (Green, 2003b; Okware et al., 2001). Older students were reached through cognitive skill-building programs such as Life Skills and Straight Talk (Green, 2003b). These programs empowered youth to make health-promoting decisions (UR) and to sustain life-affirming behaviors over time (UR) (Green, 2003b; Ruland, 2004). Later studies showed that behaviors changed the most in the cohort ages 15 to 19 in sexual debut delay, abstinence, fidelity, and condom use (Green, 2003; Herling, 2004). Additionally, President Museveni had improved the communication systems in Uganda by creating local political bodies called resistance communities or local councils in order to maintain general political control (Green, personal communication, March 13, 2008). The local council was made up of nine households. These groups were headed up by Resistance Councilors, who were trained along with district department leaders and sub-county chiefs in HIV/AIDS transmission education; de-stigmatization, care, and compassion; and condom use. The public at large was to be educated through their resistance councilor and other key people (Slutkin et al., 2006; Okware et al., 2001). The Ugandan government also prioritized the advancement of women and girls in its intervention strategy (Murphy et al., 2006; Uganda AIDS Commission Secretariat, 2002; USAID, 2002). DHS (2001) in Uganda show that the level of a woman’s education has a “strong relationship to knowledge about use of condoms or limiting sexual partners as methods of avoiding HIV/AIDS” (p. 170). PresiJournal of Integral Theory and Practice—Vol. 3, No. 4 49 K. CODER dent Museveni and his political party gave women a greater political voice; the Museveni government passed a law where one-third of Parliament members must be women (USAID, 2002). Affirmative action measures in higher institutions resulted in increases in female admissions (Green, 2003b). The government also strengthened the systemic protection of women from gender violence and sexual coercion (Wilson, 2004). In the mid 1990s, Ugandan government began to enforce a defilement law against seduction and rape of a minor that was previously rarely enforced (Green, 2003b). Green states Museveni’s interventions (LR) to advance women have created an enabling environment for primary behavior change (UR) and declining HIV infection rates (LR). Epstein (2007) notes that behavioral changes “coincided with improvements in the status of women....[and that] gender-related attitudes have also shifted” (p. 164), which shows how LR interventions can affect cultural attitudes (LL). Epstein (2007) states that what mattered most in encouraging the decline in prevalence rates was collective efficacy,7 which is the “ability for people to join together and help one another” (pp. 160-161).8 While impossible to quantify, collective efficacy is based on compassion and shared humanness. Epstein writes that Ugandans joined together through hundreds of community-based organizations in a social movement to care for and educate their fellow Ugandans, and it was “their compassion and hard work [that] brought the disease in the open, got people talking about the epidemic, reduced AIDS-related stigma and denial, and led to a profound shift in sexual norms” (p. 160). Lastly, the continuous collection of statistical data and the use of empirical studies on Ugandan behavior further strengthened the HIV/AIDS prevention campaign. Of the $18.1 million that was spent in 1989 on the National AIDS Control Program, surveillance and care garnered $4.3 million. The Ugandan government also worked closely with the WHO as well as with other international organizations that helped the country to plan and to study their strategy’s efficacy (Slutkin et al., 2006). Critical Cultural (LL) Interventions and Change in Uganda The essential combination of systemic interventions and cultural appreciation and sensitivity in the 1980s and 1990s made LR interventions more successful and resulted in healthy cultural changes in Uganda (Wilson, 2004). Samuel Okware and colleagues (2001) write that “governments must build bridges with communities to foster positive societal values that mitigate the effect of HIV/AIDS on individuals, families and dependents” (p. 1118). The Uganda AIDS Commission (2002) states that understanding local and religious values of communities is essential for strategic success. When the AIDS epidemic first emerged, a variety of reactions occurred, but as responses to the epidemic evolved, communities learned how to respond to minimize risk and maximize life-affirming activities (USAID, 2002). Nantulya writes: The community communicated internally from the very start, as fears of curses, witchcraft, and cancers gave way to the realization that this was an infectious disease transmitted through sex that affected not only “bad people” but everybody. Following this realization came a locally driven, or endogenous, common-sense, community approach—if a young person had not yet begun to have sex, then he or she should wait. If a young person had just begun to have sex, then he or she should stop. If a person was already sexually active, he or 50 Journal of Integral Theory and Practice—Vol. 3, No. 4 HIV/AIDS RATES AND UGANDA she should adopt the faithfulness/partner reduction practice of “zero grazing.” (USAID, 2002,p. 9) Nantulya reports that national strategies were developed in accordance with the early indigenous messaging created in the Ugandan communities (USAID, 2002). In this way, the Ugandan government paired systemic and structural changes (LR) with cultural sensitivity (LL), as programs were constructed through a culturally appropriate lens rather than apart from Ugandan culture.9 A major example of this thoughtfulness to cultural values is highlighted in the indigenously inspired behavior change communications campaign (Shelton et al., 2003). The indigenous HIV/AIDS messaging is likely to have been successful because it worked within the existing Ugandan worldview. Brown (n.d.) describes working within the existing worldview as a “complementary and potentially more effective” strategy in HIV/AIDS education. Congruent with the Ugandan magic-mythic-rational worldview and with the conformist identity, Ugandans were encouraged to fight against the disease as if it were an enemy in an “us” versus “them” fashion to secure the safety of Ugandans as a collective people (Epstein, 2007; Gerard Health Foundation, 2003).10 In line with their cultural norms, the Ugandan government created programs that worked through active interpersonal communications styles and community-based responses (Wilson, 2004). Programs like the IEC were “interpersonal (or face-to-face), community-based, [and] culturally-tailored” (Green, 2003b, p. 174; USAID, 2002, p. 4). As Green (2006) writes, “Ugandans are far more likely to receive AIDS information through friendships and other personal networks than through mass media or other sources and are significantly more likely to know of a friend or relative with AIDS” (p. 342; see also Green, 2004). Stoneburner (USAID, 2002) reports that Uganda was “unique in the extent to which personal communication network . . . and knowing people who had AIDS were the sources of knowledge and acknowledgment of the disease” (p. 3). Nantulya (USAID, 2002) adds that the community-level response “was vital to Uganda’s national success . . . [and that] Uganda’s early response demonstrated the importance of locally driven community-based approaches in facilitating behavior change” (p. 9).11 The IEC campaign worked to de-stigmatize HIV/AIDS, to change the Ugandan culture’s treatment of PLWHAs, and to concretize the culture’s “acceptance of HIV as a diagnosis and AIDS as a cause of death” (Ronald & Sande, 2005, p. 1064). Green (2003b) writes that one effect of the government’s support “was to reduce stigma, make open discussion of AIDS, and set the stage for sexual behavior change” (pp. 166-167). The government promoted a strategy of positive living, which is described as an encouragement to PLWHA that they can enjoy a full, meaningful life with their rights intact (DHS, 2001). In studies, personal communication networks also appear to relate to the lower levels of stigma reported in Uganda as compared to other African countries (USAID, 2002). The DHS survey of 20002001 showed that only around 10% of women and men would be unwilling to care for a relative with HIV/AIDS in their home.12 The Uganda AIDS Commission (2002) reported that even though “direct stigmatisation has [been] greatly reduced,” PLWHAs are still “indirectly isolated and denied support or access to services in various settings” (p. 14). Countrywide DHS surveys collected in 2000-2001 show that approximately 50% of women and men believe that a female teacher with HIV should not be able to continue teaching. In terms of the right to privacy for PLWHAs, less than half of women (47.4%) and less than oneJournal of Integral Theory and Practice—Vol. 3, No. 4 51 K. CODER third of men (28.2%) believed that PLWHAs should be able to keep their status confidential (DHS, 2001, pp. 174-176). Critical Intrapersonal (UL) Interventions and Change in Uganda Uganda’s successful HIV/AIDS prevention campaign appealed to the interior-individual sensibilities most prominently in messaging and communication style. The Ugandan programming on HIV/AIDS focused on the UL by activating the individual’s psychological dynamic regarding fear of death. Government-initiated interventions used fear arousal to combat denial and show that AIDS was real (Green et al., 2006). Members from the early AIDS Control Program stated that they first focused on instilling fear in the population (Green et al., 2006; Okware et al., 2001), and the IEC campaign’s initial messaging adopted “a fear approach to HIV prevention” (Green et al., 2006, p. 342; Green 2003b, pp. 178-183). Early communications efforts carried the theme, “Beware of AIDS. AIDS kills” (Green et al., 2006, p. 342). Consistent reality-based messaging educating the Ugandan public about HIV/ AIDS also served to expose myths about the disease and correct false beliefs. When asked why Ugandans changed their sexual behavior practices, the most common response was because they were afraid of AIDS (Green & Witte, 2006). Fear provoked Ugandans to feel personally vulnerable whereby motivating behavior change to stay safe from HIV infection (Green, 2003b). The act of personalization involves self-reflection and contemplation, both of which are UL phenomena. Personal knowledge of HIV/AIDS is an intrapersonal component (Brown, 2007). In Uganda, “HIV/ AIDS has been called a ‘household disease’ because nearly every household has lost a relative or friend to the disease” (DHS, 2001, p. 167). Knowledge of HIV/AIDS was and is universal (DHS, 2001).13 It may be that this universal knowledge of HIV/AIDS (UL) in combination with the open personal communications networks (LL/LR) used to educate their citizens on HIV/AIDS more effectively communicated personal risk (UL) (Green et al., 2006). This personalization of risk resulted in greater levels of behavior change (UR) (Allen & Heald, as cited in Green et al., 2006). Critical Behavioral (UR) Interventions and Change in Uganda The systemic changes that incorporated cultural and intrapersonal sensitivities significantly affected Ugandan behavior in the UR quadrant. The Ugandan AIDS Commission reports that Ugandans showed a “high level of commitment and innovativeness in fighting the epidemic” (Uganda AIDS Commission Secretariat, 2002). The relevant individual behavioral changes in the UR quadrant include sexual abstinence, delaying sexual debut, fidelity, and condom usage (Bessinger et al., 2003; Slutkin et al., 2006). In Uganda, there was a “clear trend towards delayed age of sexual debut among youth” that was significant in the late 1980s and early 1990s (Bessinger et al., 2003, p. 11). Ugandan DHS surveys between 1989 and 1995 report that sexual debut age increased by about one year for both girls and boys. In addition, delays in the onset of sexual activity manifested as the proportion of girls and boys ages 15 to 19 who reported ever having had sex decreased (p. 12). The same surveys show that ever use of condoms increased from 1% to 6% for women and reached 16% among men by 1995 (USAID, 2002). Ruth Bessinger and colleagues (2003) report that Uganda saw significant increases in condom use with non-regular partners in rural and urban areas, among 52 Journal of Integral Theory and Practice—Vol. 3, No. 4 HIV/AIDS RATES AND UGANDA youth and adults, and in men and women. However, since most sex happens within regular partnerships and few women or men reported using a condom at last sex with their regular partner, the overall proportion of Ugandans using condoms “remains relatively low” (p. 33). Uganda’s decline in HIV prevalence is associated with positive changes in all three ABC behaviors (USAID, 2003). Research shows, however, that reduction in the numbers of sexual partners was “probably the single most important behavioral change that resulted in prevalence decline” (U.S. Senate, 2003, p. 4; see also Shelton et al., 2004; Shelton et al., 2003; USAID, 2002). Studies by the WHO’s Global Programme on AIDS (GPA) report that substantial decreases in sexual behavior occurred among men and women in Uganda in the late 1980s and early 1990s (Bessinger et al., 2003). The GPA found that the number of men reporting one or more casual partners declined from 35% to 15%; women from 16% to 6% (Bessinger et al., 2003). Men reporting one or more non-regular partner decreased from 41% to 21%; women from 23% to 9%. Extramarital sex showed no decreases in women but showed a decrease from 23% to 16% in men. And, the number of men reporting three or more partners decreased by two-thirds (from 15% to 5%). It should be noted that the GPA showed declines that are much greater than those shown by the DHS in premarital sex among women and ever-had-sex rates in 15- to 19-year-old women (Bessinger et al., 2003). These estimates given by the GPA for casual partners may overstate other declines as well. Although the GPA figures may overstate declines, the GPA studies “indicate a notable reduction in high-risk sexual partners” (p. 16), and such declines in concurrent partnership activities in Ugandan men and women are profound (Shelton et al., 2004). Current Considerations: Benefits of the Integral Model Overall, the literature seems to indicate that the culturally- and personally-relevant structural and systemic changes led to cultural adjustments, shifts in consciousness, and behavior change. A particular strength of the Ugandan program was how the systemic interventions were created with the cultural reality of the Ugandan populace firmly in mind. The Ugandan government (LR), for example, incorporated the country’s cultural characteristics (LL) as the basis for the behavior change campaign messaging and overall strategy (LR). Despite past successes, there are signs in Uganda today that the newest systemic strategies to prevent the spread of HIV/AIDS are not working (Green, personal communication, October 27, 2007), and that the HIV prevalence rate is increasing again for the first time in many years (Halperin, 2007; Uganda AIDS Commission, 2007).14 Condom promotion to engender safer sex behaviors is one strategy that has been questioned (Green, 2003b; Green et al., 2007; Hearst & Chen, 2004). Henry Mosley (2005) states that condom promotion could motivate behavioral disinhibition, whereby potential users switch from a safer strategy of partner reduction to a riskier strategy of multiple partners and condom use as users perceive condoms as a safe physical barrier to protect against HIV/AIDS (see also Halperin, 2007). Studies in Rakai show that consistent condom use is only 63% effective in protecting against HIV infection and inconsistent use offers no significant protection against the disease (Ahmed, as cited in Mosley, 2005). While causality has not been established to prove that condom use causes behavioral disinhibition, studies show condom use adoption is “associated with a subsequent increase in casual sex and a lesser reduction of high-risk sexual behaviors” (USAID, 2002, p. 6). Journal of Integral Theory and Practice—Vol. 3, No. 4 53 K. CODER Similarly, Matovu et al. (2007) examined the Rakai studies’ data to research repeat voluntary HIV counseling and testing (VCT) and sexual risk behavior with regards to HIV incidence. VCT services have become a key component of HIV treatment, as they give “high-risk HIV-uninfected individuals the opportunity to change their high-risk behavior and potentially, the behavior of their sex and druguse partners” (p. 71). Matovu reported that those that use VCT more than once were significantly more likely to report inconsistent condom use than those that did not undergo VCT at all. In fact, the study’s authors suggested that repeat VCT users constitute a “special high-risk group” (p. 76) that need to be targeted with intensive risk-reduction interventions because they felt safer and engaged in riskier sexual behaviors. Green (personal communication, October 27, 2007) states that international donors have moved their support away from promoting abstinence and sexual fidelity in order to focus on condom promotion, VCT, poverty alleviation, STI treatment, and women’s empowerment, and that these new strategies have been proven to be ineffective in Africa in decreasing HIV/AIDS prevalence (see Green, 2003; Green et al., 2007). He states that the Western model of HIV/AIDS prevention is to reduce risk by promoting condoms and treating STIs while staying silent on sexual behavior practices (Green, 2003). Green reduces the West’s misguided approaches to HIV/AIDS prevention to a history of applying American models of risk reduction to African countries; its desire to separate morality from public health program design; and, its close political ties to pharmaceutical companies, which become much more profitable when planners promote treatment and condom use rather than abstinence and fidelity. The issue of women’s empowerment merits an additional explanation, as it appears that the literature presents opposing viewpoints on its efficacy in preventing and reducing the spread of HIV/AIDS (DHS, 2001; Epstein, 2007; Green, personal communication, October 27, 2007; Green 2003). Green (personal communication, February 12, 2008) explains this paradox: while he strongly affirms the need for women “to have the power to refuse unwanted sex” and the need for enforced laws against rape, defilement, enticement, violence, and abuse, he states that with women’s empowerment comes a greater likelihood that women will participate in casual and/or concurrent sexual partnerships. Therefore, it seems to be true that women’s empowerment is necessary to control the spread of AIDS, yet increased levels of empowerment can increase the spread of HIV/AIDS. The Western model values avoiding infringing on people’s personal lives, whereas the African model is confident that promoting abstinence and fidelity is “exactly the right response to AIDS” (Green, 2003, p. 5). Green and colleagues (2007) clearly state that the only way to prevent HIV transmission and to reduce HIV prevalence is through behavior change, particularly by reducing the number of multiple partnerships and by decreasing the proportion of sexually active unmarried youth. The most recent strategic plan from the Uganda AIDS Commission (2007), commenting on the recent rise in HIV prevalence, seems to echo this assessment. The plan notes: “There is a strong possibility that the negative HIV trends are at least partially attributable to phasing out of ‘zero grazing’ and other partner reduction/fidelity-focussed [sic] campaigns of the late 1980s” (p. ix). In summary, David Wilson (2004) writes that “partner reduction is good epidemiology, not good ideology, and we must ensure that the ABC approach remains sufficiently scientifically grounded to withstand shifting ideological sands” (p. 849). The use of the integral model proves beneficial as it sheds light on current considerations and events 54 Journal of Integral Theory and Practice—Vol. 3, No. 4 HIV/AIDS RATES AND UGANDA in the Ugandan HIV/AIDS strategy development process. This model exposes blind spots to truth in its attention to cultural, personal, systemic, and behavioral fundamentals. The AQAL model shows plainly that cultural and personal sensitivity were two key ingredients in the successful HIV/AIDS strategy developed and implemented by Ugandans. It also suggests that HIV/AIDS strategies that neglect to incorporate all of these elements are likely to fail in meeting their objectives (Hochachka, 2005). Conclusion The Ugandan HIV/AIDS prevention campaign that began in the mid 1980s and continued through the 1990s was highly successful and improved greatly upon Western approaches to HIV/AIDS prevention in Sub-Saharan Africa. Integral analysis shows that the Ugandan campaign incorporated elements from all four quadrants of the AQAL model. Based on the literature reviewed, the author suggests that Uganda’s informal and formal indigenous responses to HIV/AIDS honored the complexity of the epidemic, and that the integrative strategy that resulted from Uganda’s response propelled the country into successful outcomes in their efforts to change risky sexual behavior and lessen the spread of the disease. Given the current changes in priorities in HIV/AIDS prevention strategy in Uganda, the world should continue to remind itself that this remarkable feat that was accomplished through thoughtful and thorough organization, coordination, and support combined with cultural and intrapersonal appreciation and sensitivity, as this lesson remains quite relevant in current international and sustainable development efforts. Acknowledgements I would like to acknowledge those who helped me refine my analysis and those who helped with my revision process. My sincere gratitude goes to Ted Green, Alison Herling Ruark, Mark Forman, and Elijah Petersen. I also would like to thank Barrett Brown, who encouraged me to complete and submit this research, as well as my many friends who listened with seeming-interest as I waxed on about Uganda and HIV/AIDS. N OTES 1 Prevalence rates of pregnant women from antenatal clinic data are the second most popular type of measure used to estimate HIV prevalence in the general population if data from general population samples are unavailable. See UNAIDS/ MAP, “The Report from the Durban Monitoring the AIDS Pandemic (MAP) Network Symposium,” July 2000, p. 15. 2 The stance taken is based on the literature reviewed, including the following: Epstein, The invisible cure: Africa, the West, and the fight against AIDS, 2007; Green, Rethinking AIDS prevention: Learning from success in developing countries, 2003; Green et al., “Uganda’s HIV prevention success: The role of sexual behavior change and the national response,” 2006; Hearst & Chen, “Condom promotion for AIDS prevention in the developing world: Is it working?,” 2004; Robinson et al., “Type of partnership and heterosexual spread of HIV infection in rural Uganda: Results from simulation modeling,” 1999; Shelton et al., “Partner reduction in HIV prevention: The neglected middle child of ‘ABC,’” 2003; Shelton et al., “Partner reduction is crucial for balanced “ABC” approach to HIV prevention,” 2004; Stoneburner & Low-Beer, “Population-level HIV declines and behavioral risk avoidance in Uganda,” 2004; USAID, “What happened in Uganda? Declining HIV prevalence, behavior change, and the national response,” 2002, p. 9; Wilson, “Partner reduction and the prevention of HIV/AIDS,” 2004. 3 Green is beginning to study concurrency in Uganda. He theorizes that multi-partner sex was casual and that there was some concurrency, but that concurrency was not the norm. Concurrent sexual relations imply a long-term partnering, while multi-partner sex does not. Journal of Integral Theory and Practice—Vol. 3, No. 4 55 K. CODER Wilber warns against propagating the premodern (ubuntu) versus modern (Western) value systems comparison without recognizing that while premodern values are more cohesive than tribal values, modern values are more cohesive than premodern values (personal communication, September 23, 2008). 5 See Edwards, “Societal complexity and moral development: A Kenyan study,” 1975, for a study of the moral development of Kenyan elders in tribal villages as compared to Kenyan university students. 6 Notably, limited data in Kampala show a significant recent increase in the HIV prevalence rate among commercial sex workers from 28% to 47% in 2000-2003 while condom usage has remained universal. This dichotomy raises questions as to whether prevalence increases are due to fast transmission in this high-risk group and/or whether those infected are more likely to engage in commercial sex (STD/ACP, STD/HIV/AIDS surveillance report, 2003, p. 48). 7 The term collective efficacy was coined by sociologist Felton Earls. 8 Collective efficacy has a correlate concept in Integral Theory, which is called nexus agency. 9 See discussion of the importance of culturally-driven responses in Uganda’s success in lowering HIV/AIDS prevalence in Epstein, The invisible cure: Africa, the West, and the fight against AIDS, 2007, p. 181; Green, Rethinking AIDS prevention: Learning from success in developing countries, 2003, p. 174; USAID, “The ‘ABCs’ of HIV prevention,” 2002, p. 3, and discussions of the failure of programming that ignores culture: Epstein, The invisible cure: Africa, the West, and the fight against AIDS, 2007, p. 169; USAID, “The ‘ABCs’ of HIV prevention,” 2002, p. 9. 10 Epstein writes that mobilizing against a common enemy does seem to work, and that Uganda recognized early on that HIV was the enemy. See Epstein, The invisible cure: Africa, the West, and the fight against AIDS, 2007, p. 254. 11 Epstein also reports that the introduction of home-based care in Uganda served to lower stigma against PLWHAs. See The invisible cure: Africa, the West, and the fight against AIDS, 2007, p. 166. 12 10.7% of women and 8.9% of men would be unwilling to care for a relative with AIDS at home (pp. 175-176). 13 Based on studies in 1995 and 2000-2001. 14 The newest strategies in Uganda focus on condom use, VCT, women’s empowerment, STI treatment, and poverty reduction, and they have moved away from Uganda’s original priorities (in order of importance): partner reduction, delaying sexual debut, and condom use. 4 R EFERENCES AIDS “outruns” international efforts. (2005). The Journal for the Royal Society for the Promotion of Health, 125(4), 150. Bangura, Abdul. (2005). Ubuntogogy: An African educational paradigm that transcends pedagogy, androgogy, ergonagy and heutagogy. Journal of Third World Studies, 22(2), 13-44. Bessinger, Ruth, Akwara, Priscilla, & Halperin, Daniel. (2003). Sexual behavior, HIV and fertility trends: A comparative analysis of six countries; Phase I of the ABC study. Measure Evaluation/USAID. Retrieved October 7, 2007, from http://www.cpc. unc.edu/measure/publications/special/ special.html Brown, Barrett. (2006). Theory and practice of integral sustainable development: Part 1-Quadrants and the practitioner. AQAL: 56 Journal of Integral Theory and Practice—Vol. 3, No. 4 Journal of Integral Theory and Practice, 1(2), 366-405. Brown, Barrett. (2007). The four worlds of sustainability: Drawing upon four universal perspectives to support sustainability initiatives. Retrieved September 23, 2007, from http://multiplex.integralinstitute. org/Public/cs/files/43/sustainability/entry19624.aspx Brown, Barrett. (n.d.). How to tailor public communications about HIV/AIDS to different worldviews. Unpublished manuscript. Cook-Greuter, Susanne. (n.d.). Ego development: Nine levels of increasing embrace. Retrieved March 6, 2007, from http:// www.cook-greuter.com/ Demographic Health Surveys. (2001). Uganda: Standard DHS, 2001/01. Chapter 11: HIV/AIDS and other sexually transmitted infections. Retrieved November 5, 2007, from http://www.measuredhs.com/pubs/ pub_details.cfm?ID=346 HIV/AIDS RATES AND UGANDA Edwards, Carolyn. (1975). Societal complexity and moral development: A Kenyan study. Ethos, 3(4), 505-527. Epstein, Helen. (2004). The fidelity fix. New York Times. Retrieved on November 5, 2007, from http://www.nytimes.com Epstein, Helen. (2007). The invisible cure: Africa, the West, and the fight against AIDS. New York: Farrar, Straus and Giroux. Friedman, Joseph. (2005). Ethiopian civil service transformational leadership development program: Day 1 [PowerPoint Presentation]. Gerard Health Foundation (Producer). (2003). What happened in Uganda? An African solution to a global problem [Video online]. Retrieved March 6, 2007, from http://www.rosenbergcommunications. com/broadcast_watch_uganda.html Green, Edward. (2000). Traditional healers and AIDS in Uganda. Journal of Alternative and Complementary Medicine, 6(1), 1-2. Green, Edward. (2003a). Culture clash and AIDS prevention. The Responsive Community, 13(4), 4–9. Retrieved November 19, 2006, from http://www.gwu. edu/~ccps/rcq/rcq-archives.html Green, Edward. (2003b). What we can learn from Uganda? In Rethinking AIDS prevention: Learning from success in developing countries (pp. 141-226). Westport, CT: Praeger. Green, Edward, Halperin, Daniel, Nantulya, Vinand, & Hogle, Janice. (2006). Uganda’s HIV prevention success: The role of sexual behavior change and the national response. AIDS and Behavior, 10(4), 335346. Green, Edward, Ruteikara, Sam, & Hearst, Norman. (2007). Economic-ideological imperialism and the premature death of the Uganda approach to AIDS [Unpublished Op-Ed article]. Green, Edward, & Witte, Kim. (2006). Can fear arousal in public health campaigns contribute to the decline of HIV prevalence? Journal of Health Communication, 11, 245-259. Halperin, Daniel. (2007, January). Evidencebased behavior change HIV prevention approaches for Sub-Saharan Africa [Video and PowerPoint Presentation]. Presented at the Harvard University Program on AIDS Seminar Series. Retrieved January 17, 2008, from http://www.harvardaidsprp.org/symposia-events/HalperinHUPApresentation011707.html Hanks, Tammy. (2008). The ubuntu paradigm: Psychology’s next force? Journal of Humanistic Psychology, 48(1), 116-135. Harkness, Sara, Edwards, Carolyn Pope, & Super, Charles. (1981). Social roles and moral reasoning: A case study in a rural African community. Developmental Psychology, 17(5), 595-603. Hearst, Norman, & Chen, Sanny. (2004). Condom promotion for AIDS prevention in the developing world: Is it working? Studies in Family Planning, 35(1), 39-47. Herling, Allison. (2004). Delaying sexual debut among Uganda’s youth: Evidence and implications [PowerPoint Presentation]. Presented at the CCIH Annual Conference. Hochachka, Gail. (2005). Developing sustainability, developing the self: An Integral approach to international and community development. Retrieved December 8, 2007, from http://www.drishti.ca/resources.htm Hochachka, Gail. (2006). Developing leadership from within: Use of the Integral framework in UNDP’s Leadership For Results Programme to reverse the HIV/AIDS epidemic. Retrieved October 10, 2007, from http://www.drishti.ca/resources.htm Hochachka, Gail. (2008). Case studies in integral approaches in international development: An integral research project. Journal of Integral Theory and Practice, 3(2), 58-108. Kaleeba, Noerine, Namulondo Kadowe, Joyce, Journal of Integral Theory and Practice—Vol. 3, No. 4 57 K. CODER Kalinaki, Daniel, & Williams, Glen. (2000). Open secret: People facing up to HIV and AIDS in Uganda (Strategies for Hope Series no. 15). London: ActionAIDS. Karsten, Luchien, & Illa, Honorine. (2005). Ubuntu as a key African management concept: Contextual background and practical insights for knowledge application. Journal of Managerial Psychology, 20(7), 607-620. Kohlberg, Lawrence. (1984). The psychology of moral development: The nature and validity of moral stages. San Francisco, CA: Harper & Row. Kohlberg, Lawrence, Levine, Charles, & Hewer, Alexandra. (1983). Moral stages: A current formulation and a response to critics. Contributions to Human Development, 10, 1-174. Lambley, Peter. (1973). Psychology and sociopolitical reality: Apartheid psychology and its links with trends in humanistic psychology and behavior theory. International Journal of Psychology, 8(1), 7379. MAP. (2000). Report of the Durban monitoring the AIDS pandemic (MAP) network symposium. Retrieved October 5, 2007, from http://www.thebody.com/content/ world/ art34662.html Maslow, Abraham. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. Matovu, Joseph, Gray, Ronald, Kiwanuka, Noah, Kigozi, Godfrey, Wabwire-Mangen, Fred, Nalugoda, Fred, Serwadda, David, Sewankambo, Nelson, & Wawer, Maria. (2007). Repeat voluntary HIV counseling and testing (VCT), sexual risk behavior and HIV incidence in Rakai, Uganda. AIDS Behavior, 11, 71-78. Mickunas, Algis. (1997). An introduction to the philosophy of Jean Gebser. Integrative Explorations, 4(1), 8-20. Retrieved 58 Journal of Integral Theory and Practice—Vol. 3, No. 4 March 10, 2007, from http://www.gebser. org/IE.html Mnyaka, Mluleki, & Motlhabi, Mokgethi. (2005). The African concept of Ubuntu/ Botho and its socio-moral significance. Black Theology: An International Journal, 3(2), 215-237. Morris, Martina, & Kretzschmar, Mirjam. (1997). Concurrent partnerships and the spread of HIV. AIDS, 11, 641-648. Mosley, Henry. (2005). The ABC’s of AIDS prevention: What’s the controversy? [PowerPoint Presentation]. Presented at the CCIH Conference. Murphy, Elaine, Greene, Margaret, Mihailovic, Alexandra, & Olupot-Olupot, Peter. (2006). Was the “ABC” approach (abstinence, being faithful, using condoms) responsible for Uganda’s decline in HIV? Public Library of Science Medicine, 3(9), 1-5. Murove, Munyaradzi. (2004). An African commitment to ecological conservation: The Shona concepts of ukama and ubuntu. Mankind Quarterly, 45(2), 195-215. Okware, Sam, Opio, Alex, Musinguzi, Joshua, & Waibale, Paul. (2001). Fighting HIV/ AIDS: Is success possible? Bulletin of the World Health Organization, 79(12), 11131120. Robinson, Noah, Mulder, Daan, Auvert, Bertran, Whitworth, Jimmy, & Hayes, Richard. (1999). Type of partnership and heterosexual spread of HIV infection in rural Uganda: Results from simulation modeling. International Journal of STD & AIDS, 10, 781-725. Roehr, Bob. (2005). Abstinence programmes do not reduce HIV prevalence in Uganda. British Medical Journal, 330, 496. Rogoff, Barbara. (2003). The cultural nature of human development. New York: Oxford University Press. Ronald, Allan, & Sande, Merle. (2005). HIV/ AIDS care in Africa today. Clinical Infectious Diseases, 40(7), 1045-1048. HIV/AIDS RATES AND UGANDA Ruland, Claudia. (2004). Abstinence and delayed sexual initiation for youth. Published by Family Health International (FHI)/Youth Net. Retrieved November 5, 2007, from http://www.fhi.org Sekirevu, David, & Lukenge, Daniel. (1998, July). People living with HIV/AIDS reaching out to schools [Abstract]. 12th Eorld AIDS Conference: Geneva. STD/AIDS Control Programme. (2003). STD/ HIV/AIDS surveillance report. Kampala, Uganda: Ministry of Health. Shelton, James, Halperin, Daniel, Nantulya, Vinand, Potts, Malcolm, Gayle, Helene, & Holmes, King. (2003). Partner reduction in HIV prevention: The neglected middle child of “ABC.” Retrieved November 10, 2006, from www.aidsuganda.org Shelton, James, Halperin, Daniel, Nantulya, Vinand, Potts, Malcolm, Gayle, Helene, & Holmes, King. (2004). Partner reduction is crucial for balanced “ABC” approach to HIV prevention. British Medical Journal, 328, 891-893. Slutkin, Gary, Okware, Sam, Naamara, Warren, Sutherland, Don, Flanagan, Donna, Carael, Michel, Blas, Erik, Delay, Paul, & Tarantola, Daniel. (2006). How Uganda reversed its HIV epidemic. AIDS and Behavior, 10, 351-361. Stoneburner, Rand & Low-Beer, Daniel. (2004). Population-level HIV declines and behavioral risk avoidance in Uganda. Science, 304, 714-718. Thompson, Gardner. (2003). Governing Uganda: British colonial rule and its legacy. Kampala, Uganda: Foundation Publishers Limited. Ugandan AIDS Commission. (2007). Moving toward universal access: National HIV & AIDS strategic plan 2007/8–2011/12. Republic of Uganda. Uganda AIDS Commission Secretariat. (2002). HIV/AIDS in Uganda: The epidemic and the response. Retrieved November 5, 2007, from www.aidsuganda.org/pdf/ hiv_aids_impact.pdf Uganda Ministry of Health. (1999). An overview of HIV/AIDS in Uganda [PowerPoint Presentation]. Retrieved on October 24, 2007, from http://www.health.go.ug/ pubs.htm Uganda Ministry of Health. (n.d.). HIV graphs and charts. More on HIV/AIDS in Uganda: Table 7: Cumulative reported AIDS cases by year. Retrieved October 24, 2007, from http://www.health.go.ug/hiv_graphs.htm USAID. (2002). What happened in Uganda? Declining HIV prevalence, behavior change, and the national response. Hogle, J. A. (Ed.), Project Lessons Learned Case Study. Retrieved March 6, 2007, from www.usaid.gov/our_work/global_health/ aids/ Countries/africa/uganda_report.pdf USAID. (2003). The ABCs of HIV prevention: Report of a USAID technical meeting on behavior change approaches to primary prevention of HIV/AIDS. Retrieved November 10, 2006, from www.aidsuganda. org USAID. (2006). The ABCs of HIV prevention [Factsheet]. Retrieved January 5, 2008, from http://www.usaid.gov/our_work/ global_health/aids/News/abcfactsheet. html UNAIDS. (2006). Chapter 2: Overview of the global AIDS epidemic. 2006 Report on the Global AIDS Epidemic. Retrieved March 7, 2006, from http://www.unaids. org/en/HIV_data/2006GlobalReport/default.asp UNDP, UNAIDS, & World Bank. (2006). Mainstreaming HIV and AIDS in sectors & programmes: An implementation guide for national responses. Annex 2, p. 105-106. Retrieved January 4, 2008, from www.undp.org/hiv/docs/alldocs/MainstreamingB.pdf U.S. Senate Foreign Relations Committee, African subcommittee. (2003). Senate testimony of Dr. Edward C. Green on May Journal of Integral Theory and Practice—Vol. 3, No. 4 59 K. CODER 19, 2003. Retrieved November 10, 2006, from www.stwr.net Van Dyk, G., & Nefale, M. (2005). The split-ego experience of Africans: Ubuntu therapy as a healing alternative. Journal of Psychotherapy Integration, 15(1), 48-66. Van Vlaenderen, Hilde. (1999). Problem solving: A process of reaching common understanding and consensus. South African Journal of Psychology, 29(4), 166-177. Wilber, Ken. (2000). The evolution of consciousness. In A brief history of everything (2nd ed.). Boston, MA: Shambhala. Wilber, Ken. (2006). Integral spirituality. Boston: Integral Books. Wilson, David. (2004). Partner reduction and the prevention of HIV/AIDS. British Medical Journal, 328, 848-849. KATHERINE CODER is a doctoral candidate studying transpersonal clinical psychology at the Institute of Transpersonal Psychology in Palo Alto, California. Her interest in international development began with her service in Peace Corps Haiti (2002–2004) where she worked as a micro-enterprise development adviser to two women’s and girl’s collectives in the fishing village of Abricots. Her other research interests include socially-engaged spirituality and individual and social transformation as well as Integral Theory. 60 Journal of Integral Theory and Practice—Vol. 3, No. 4